USMLE STEP 2 EXAM QUESTIONS WITH VERIFIED
ANSWERS
Essential HTN
(95% of cases)...no identifiable cause
Secondary HTN most common cause? In young women?
Renal artery stenosis, in young women = OCPs
BP classifications
Normal:
Prehypertension:
Stage I:
Stage II:
Normal: < or = 120/80
Prehypertension: > 120/80 but <140/90
Stage I: > or = 140/90
Stage II: > or = 160/100
Hypertensive urgency
Severe HTN (>180, >120) in asymptomatic patient
Hypertensive emergency
Severe HTN (>180, >120) + End organ damage
What counts as end organ damage in HTN emergency?
1. Worst headache
2. AMS - HTNsive encephalopathy
3. Papilledema
4. Stroke
5. CP/MI
6. SOB from acute heart failure and flash pulm edema
7. Aortic dissection/big vessel issue
8. Creatinine bump, BUN bump, UA: proteinuria, hematuria
Treatment of HTNsive emergency
IV nitroprusside or IV labetalol
Treatment of HTNsive urgency
IV hydralazine.... But watch for orthostatic hypotension
Or just increase dose of one of their home antihypertensives
TX of prehypertension
#1. Lifestyle modifications
- weight loss (#1)
- DASH diet (low fat, more fruits and veggies)
- Exercise
- Salt intake <4g or <2g per day
- avoid alcohol
Secondary HTN differential
,1. Renal artery stenosis
2. Chronic renal failure
3. PCKD
4. Hyperaldosteronism
5. Hyperthyroid
6. Cushings
7. Pheochromocytoma
8. Acromegaly
9. Coarct of the aorta
10. Obstructive sleep apnea
Drugs causing HTN
Birth control pills
Decongestants
Estrogen
Appetite suppressants
Chronic steroids
TCAs
NSAIDs
Drugs of abuse (cocaine, etc.)
End organ damage from HTN
1. Heart - CAD leading to MI, CHF from increased after load and LVH dilation
2. Vascular - increased risk of AAA, aortic dissection, PAD
3. Brain - stroke, TIA due to atherosclerosis of cerebral vessels
4. Atherosclerosis of efferent and afferent arterioles = decreased GFR = CKD
5. Visual disturbances/ scotomata from retinopathy
AV nicking
Discontinuity in the retinal vein due to thickened arterial walls = early damage from HTN
Retinal hemorrhages and exudates
A sign of more serious HTNsive disease
Papilledema
Swelling of the optic disk...a sign of increased increased inter-cranial pressure
Diagnosis of HTN
At least 2 BP readings over a span of 4 or more weeks
...if white coat HTN is suspected you can:
1. 24 hour BP monitoring
2. Home BP monitoring
Cotton wool spots
Infarction of the nerve fiber layer in the retina = early damage from HTN
If HTN is diagnosed which tests to order to evaluate for end organ damage and assess
cardiovascular risk?
1. UA
2. CMP (serum K+, BUN, Cr)
3. Fasting glucose
4. Lipid panel
5. EKG
, HTN GOALS...
1. For general population > 60:
2. For general population < 60:
3. For diabetics without CKD:
4. For diabetics with CKD:
1. <150/<90
2. <140/<90
3. <140/<90
4. <140/<90
First line TX for African American patient with HTN
Thiazide diuretic or CCB
First line TX for osteoporosis patient with HTN
Thiazide diuretic (increases Ca++ reabsorption in the nephron)
First line TX for CHF, CAD, or Afib patient with HTN
Beta blocker (slows heart rate and anti-arrythmogenic) or ACE inhibitor
First line TX for heart block patient with HTN
NOT BETA BLOCKER because it slows the HR and decreases CO
First line TX for lung disease patient with HTN
NOT BETA BLOCKER because beta receptors dilate the airway
First line TX for diabetic patient with HTN
ACE inhibitor (because these are protective on the kidneys) or ARB
Second line drugs for refractory HTN
- vasodilators (hydralazine, minoxidil)
First line TX for diabetic patient with HTN who develops chronic cough from ACE
inhibitor
ARB
First line drugs for initial monotherapy of HTN
CCB (dihydropyridine), thiazide diuretics, ACE inhibitors or ARBs
First line TX for CKD patient with HTN
ACE inhibitor (because these are protective on the kidneys) or ARB
Drug which would help BP and BPH at the same time
alpha blockers
Thiazide diuretics side effects
1. HYPO K+, Mg++
2. HYPER uricemia, glycemia, lipidemia (CHL, TGs)
3. Metabolic alkalosis
Beta blocker side effects
1. Bradycardia
2. Bronchospasm
3. May increase TGs and decrease HDL
4. May mask hypoglycemic sx in diabetics
5. Insomnia, fatigue, sedation
6. Depression
ACE inhibitor side effects
1. Acute renal failure (in those with pre-existing renal artery stenosis)
2. HYPER K+
ANSWERS
Essential HTN
(95% of cases)...no identifiable cause
Secondary HTN most common cause? In young women?
Renal artery stenosis, in young women = OCPs
BP classifications
Normal:
Prehypertension:
Stage I:
Stage II:
Normal: < or = 120/80
Prehypertension: > 120/80 but <140/90
Stage I: > or = 140/90
Stage II: > or = 160/100
Hypertensive urgency
Severe HTN (>180, >120) in asymptomatic patient
Hypertensive emergency
Severe HTN (>180, >120) + End organ damage
What counts as end organ damage in HTN emergency?
1. Worst headache
2. AMS - HTNsive encephalopathy
3. Papilledema
4. Stroke
5. CP/MI
6. SOB from acute heart failure and flash pulm edema
7. Aortic dissection/big vessel issue
8. Creatinine bump, BUN bump, UA: proteinuria, hematuria
Treatment of HTNsive emergency
IV nitroprusside or IV labetalol
Treatment of HTNsive urgency
IV hydralazine.... But watch for orthostatic hypotension
Or just increase dose of one of their home antihypertensives
TX of prehypertension
#1. Lifestyle modifications
- weight loss (#1)
- DASH diet (low fat, more fruits and veggies)
- Exercise
- Salt intake <4g or <2g per day
- avoid alcohol
Secondary HTN differential
,1. Renal artery stenosis
2. Chronic renal failure
3. PCKD
4. Hyperaldosteronism
5. Hyperthyroid
6. Cushings
7. Pheochromocytoma
8. Acromegaly
9. Coarct of the aorta
10. Obstructive sleep apnea
Drugs causing HTN
Birth control pills
Decongestants
Estrogen
Appetite suppressants
Chronic steroids
TCAs
NSAIDs
Drugs of abuse (cocaine, etc.)
End organ damage from HTN
1. Heart - CAD leading to MI, CHF from increased after load and LVH dilation
2. Vascular - increased risk of AAA, aortic dissection, PAD
3. Brain - stroke, TIA due to atherosclerosis of cerebral vessels
4. Atherosclerosis of efferent and afferent arterioles = decreased GFR = CKD
5. Visual disturbances/ scotomata from retinopathy
AV nicking
Discontinuity in the retinal vein due to thickened arterial walls = early damage from HTN
Retinal hemorrhages and exudates
A sign of more serious HTNsive disease
Papilledema
Swelling of the optic disk...a sign of increased increased inter-cranial pressure
Diagnosis of HTN
At least 2 BP readings over a span of 4 or more weeks
...if white coat HTN is suspected you can:
1. 24 hour BP monitoring
2. Home BP monitoring
Cotton wool spots
Infarction of the nerve fiber layer in the retina = early damage from HTN
If HTN is diagnosed which tests to order to evaluate for end organ damage and assess
cardiovascular risk?
1. UA
2. CMP (serum K+, BUN, Cr)
3. Fasting glucose
4. Lipid panel
5. EKG
, HTN GOALS...
1. For general population > 60:
2. For general population < 60:
3. For diabetics without CKD:
4. For diabetics with CKD:
1. <150/<90
2. <140/<90
3. <140/<90
4. <140/<90
First line TX for African American patient with HTN
Thiazide diuretic or CCB
First line TX for osteoporosis patient with HTN
Thiazide diuretic (increases Ca++ reabsorption in the nephron)
First line TX for CHF, CAD, or Afib patient with HTN
Beta blocker (slows heart rate and anti-arrythmogenic) or ACE inhibitor
First line TX for heart block patient with HTN
NOT BETA BLOCKER because it slows the HR and decreases CO
First line TX for lung disease patient with HTN
NOT BETA BLOCKER because beta receptors dilate the airway
First line TX for diabetic patient with HTN
ACE inhibitor (because these are protective on the kidneys) or ARB
Second line drugs for refractory HTN
- vasodilators (hydralazine, minoxidil)
First line TX for diabetic patient with HTN who develops chronic cough from ACE
inhibitor
ARB
First line drugs for initial monotherapy of HTN
CCB (dihydropyridine), thiazide diuretics, ACE inhibitors or ARBs
First line TX for CKD patient with HTN
ACE inhibitor (because these are protective on the kidneys) or ARB
Drug which would help BP and BPH at the same time
alpha blockers
Thiazide diuretics side effects
1. HYPO K+, Mg++
2. HYPER uricemia, glycemia, lipidemia (CHL, TGs)
3. Metabolic alkalosis
Beta blocker side effects
1. Bradycardia
2. Bronchospasm
3. May increase TGs and decrease HDL
4. May mask hypoglycemic sx in diabetics
5. Insomnia, fatigue, sedation
6. Depression
ACE inhibitor side effects
1. Acute renal failure (in those with pre-existing renal artery stenosis)
2. HYPER K+
